What are the guidelines for initiating Hormone Replacement Therapy (HRT)

Guidelines for Initiating Hormone Replacement Therapy (HRT)

HRT should be used at the lowest effective dose that alleviates symptoms for the minimum time necessary, with careful consideration of individual risks and benefits. 1, 2

General Principles for HRT Initiation

• HRT is not recommended for routine use in the primary prevention of chronic conditions in postmenopausal women 3
• HRT should be considered primarily for the treatment of menopausal symptoms such as vasomotor symptoms and vaginal atrophy 3, 4
• The benefit-risk balance is most favorable for women with severe vasomotor symptoms who are ≤60 years old or within 10 years of menopause onset 1, 3
• A shared decision-making approach should be used, considering individual risk factors and preferences 3

Risk Assessment Before Initiating HRT

• Assess for contraindications including:

  • History of breast cancer 1
  • Coronary heart disease 3
  • Previous venous thromboembolic events or stroke 3
  • Active liver disease 1
  • Antiphospholipid antibody status (avoid HRT in women with positive aPL or APS) 3

• Evaluate baseline risk for:

  • Cardiovascular disease 3
  • Venous thromboembolism 3
  • Breast cancer 3
  • Osteoporosis 3

Dosing Recommendations

• Start with the lowest effective dose 4, 5

  • For oral estradiol: 0.3-1 mg daily initially 4, 6
  • For transdermal estradiol: 25-50 μg/day via patches 1, 7

• For women with an intact uterus, add progestin to reduce endometrial cancer risk 1, 4

  • Micronized progesterone is preferred due to lower cardiovascular and venous thromboembolism risk 1
  • Dydrogesterone is an acceptable alternative 3, 2

• Consider route of administration based on individual factors:

  • Transdermal administration shows better profiles for bone mass accrual and cardiovascular risk 1, 7
  • Transdermal route is preferred for women with hypertriglyceridemia 7

Special Populations

• Women with premature ovarian insufficiency (POI):

  • HRT is generally recommended until the average age of natural menopause (51 years) 3
  • For adolescents with POI, start with low-dose estrogen and gradually increase over 2-3 years 3

• Women with rheumatic and musculoskeletal diseases:

  • Women without SLE and without positive aPL can be treated according to general postmenopausal guidelines 3
  • Strongly avoid HRT in women with obstetric and/or thrombotic APS 3

• Women after breast cancer:

  • HRT is generally contraindicated in breast cancer survivors 3

Patient Education and Monitoring

• Inform women about potential risks and benefits:

  • Risks include increased risk for venous thromboembolism, stroke, and cardiovascular events within 1-2 years of therapy 3, 2
  • Risk of breast cancer appears to increase with longer-term HRT 3, 2
  • Benefits may include reduced risk for fractures and colorectal cancer 3, 2

• Reevaluate periodically (every 3-6 months) to determine if treatment is still necessary 4, 8

  • Consider attempting to discontinue or taper medication at 3-6 month intervals 4
  • Treatment can be stopped immediately or gradually based on patient preference 8

Common Pitfalls to Avoid

• Initiating HRT solely for prevention of chronic diseases rather than symptom relief 3
• Using higher doses than necessary, which may increase side effects and risks 5, 6
• Continuing HRT longer than needed for symptom control 9
• Failing to add progestin for women with an intact uterus 1, 4
• Not considering alternative treatments for menopausal symptoms in women with contraindications to HRT 3